Autonomy in Old Age Prof. Dr. Tineke A. Abma Research Programme - - PowerPoint PPT Presentation

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Autonomy in Old Age

• Prof. Dr. Tineke A. Abma

Department of Medical Humanities

Introduction

• The older population is rapidly growing
• In many European, aging countries the welfare

state is redesigned, because of costs

• More responsibilities are assigned to older people,

they need to become self-sufficient

• Most of them stay at home, about 8% is

institutionalized in nursing homes

• Context of not enough care to be autonomous
• Context with a risk of overruling the autonomy

Questions

• How can older people remain in control over their

lives in various contexts?

• To what extent does the autonomy concept help

to understand ethically problematic situations?

• Two case examples, and contexts: hospital and

nursing home

• Two perspectives on autonomy

Autonomy as a concept/principle

• Became popular with rise of bioethics after 2e WO
• The professional is in the position of power and

authority over the patient

• The patient needs to be protected
• Now one of the four principles in bioethics,

besides: doing good, doing no harm, and justice (Childress & Beaucamp)

• Has been broadly accepted in Western healthcare

and healthcare policy, including elderly care

Autonomy as self-determination

• According to principle ethics:

– The patient is independent, determines and steers on his own behalf – Patient is fully informed, oversees information – Patient knows his own needs, preferences and values – Patient has the freedom of choice and can decide for himself – Healthcare professional as information-provider – No interference with the decision

Case example, Mrs. Caring

• Mrs. Caring, 81 years-old, husband died five years

ago, three children. Care is core value in life

• Suffered from non-hodgkin cancer
• Received treatment to increase quality-of-life (vs

length)

• Broke her hip one night, entered hospital
• The staff preferred an operation, Mrs. Caring did

not want the operation but pain medication

• The staff did not give pain medication

• Mrs. Caring
• Her oncologist approved Mrs. Caring was

terminally ill, suffered from pain and had a wish to die

• Her family also confirmed her wish: she had been

lonely since her husband died

• Life had no longer meaning and purpose if she

could not take care for and care about others

• Finally she was given pain medication, after 5

days she died

Evaluation of case Mrs. Caring

• Mrs. Caring was competent: she had a stable

wish, oversaw the information

• Hierarchic relations did not favour and encourage

her autonomy

• There was not an open conversation among the

staff on the moral dilemma

• Oncologist and family played important role: they

knew what mattered to Mrs. Caring, her identity and personal history

• Autonomy concept does not fully capture the

situation

Case 2, Mr Powell

• Mr. Powell, 92 years old, since five year a

widower, three sons who all live far away

• Held several managerial functions: inspector

police force, Ministry Economic Affairs

• Was admitted to nursing home after he neglected

himself (not intake of food), a fall, diabetes

• Identified himself as a scout: doing one good deed

a day

• He was frail, but very willing to help others

Case 2, Mr. Powell

• Mr. Powell came up with ideas to improve the

quality of life in the nursing home

• The staff did not encourage Mr Powell to help
• thers, no positive response to his plans
• Mr. Powell felt disappointed, stopped with his

initiatives, felt even more lonely

• The traditional concept of autonomy does not help

to address what is ethically problematic in this situation

Evaluation Case Mr. Powell

• Children interfered to get Mr. Powell admitted to a

nursing home for safety reasons

• Mr. Powell tried to remain himself and in control of

his life by acting as he always acted

• The staff discouraged the use of another person

as support (focus on physical health and safety)

• The staff was averse of dependence, reinforced

notion of persons as isolated, egoistic individuals

• Opposite effect on the social fabric in the home,

and well-being Mr Powell

Is autonomy realistic in old age?

• George J. Agich (1993), phenomenologist

– Critique on idealization of autonomy as a competent rational free agent – Focus on what autonomy actually means in the everyday world – Is autonomy as self-determination suitable for all situations and contexts?

For example nursing homes where staff is underpaid and overworked, more complicated relationships in long-term care than medical context, less discrete decisions

– Is this suitable for all older people?

For example people with Alzheimer or cognitive impairments

Other critical questions

• Raised by care-ethicists (Joan Tronto):

– Sometimes non-intervention can lead to more misery For example: older people who do not want to take food, get out of

bed, do not want to shower …

– Cognitively oriented (competence), while personal values and identity are equally important – People are not isolated individuals, we need

• thers to become autonomous

Autonomy as self-development

• Inspired by care-ethicists

– Autonomy is relational, someone is not autonomous despite but because of others – Autonomy and dependence are not opposites – Self-respect develops via respect by others – Autonomy develops over life-time, through trial and error – Autonomy is exploring your own life-path, values, identity and story (authenticity)

Comparing the two perspectives on autonomy Negative versus positive freedom Self-determination Self-development

Free until freedom others Increase of freedom Content does not matters Content does matter Independent Interdependent

Good care

‘Respecting autonomy requires attending to those things that are truly and significantly meaningful and important for elders’ (Agich, 1993, p. 113).

• This requires ‘identification’ of the concrete person
• Creating conditions that foster the values, identity

and life-path of that person

• Content matters: making decisions in line with the

life-path and value commitments (vs impulses)

• We need others to realize our identity, to warn us,

to set norms, to find alternatives

Good care may require intervention

• This starts with motivation and support to help to

person to come to the right decision (Moody, 1992)

• This may require re-interpretation and

deliberation of the values important in life

• The professional is more than information-giver

and expert, more like a wise friend

• One might consider coercion and compassionate

interference but only if motivation and support do not work

• Only, if it heightens a person’s self-development
• Only, if one evaluates the action

Ambivalence to the care of the old

• We support non-interference, regardless of

personal costs > Mrs. Caring having to stay at home despite her frailty, and later not receiving pain medication

• We adhere to (nursing-home) care, where

autonomy is gives way to sometimes abject dependence > Mrs. Caring not allowed to die > Mr. Powell’s not being able to act as Scout

Conclusions

– Society is ambivalent to autonomy in care for the old – Autonomy concept not always helpful to understand ethically problematic situations – We should not idealize autonomy as a competent rational free agent – Focus instead on what autonomy actually means in the everyday world – This implies conditions fostering self- development, identity and values – Dialogue to discuss moral dilemma's

References

• Abma, T.A. & G.A.M. Widdershoven (2014) Dialogical Ethics and

Responsive Evaluation as a Framework for Patient Participation, AJOB, 14(6): 27-29. DOI:10.1080/15265161.2014.900143.

• Abma, T.A. & V. Baur (2014) User involvement in long-term care. Toward

a care ethics approach. Health Expectations, 27 April 2014. DOI: 10.1111/hex.12202.

• Abma, T.A., A. de Bruijn, J. Schols, T. Kardol & G.A.M. Widdershoven

(2012) Responsibilities in elderly care. Mr Powell’s narrative of duty and

• relations. Bioethics. 26(1):22-31.Doi: 10.1111/j.1467-8519.2011.01898.x